Please list the names of any friends or family currently in the practice:

List any sports, hobbies, or musical instruments played:

Whom may we thank for referring you to our practice?

Confidential Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment.

*First Name

Middle Initial

*Last Name

Marital Status

Relationship to Patient

*Birthdate

*Address

*City

*State

*Zip

How long at this address?

Previous Address (less than 3 years)

Email

*Main Phone

2nd/Cell Phone

Work Phone #

Social Security #

Employer

Occupation

Length of Employment

Spouse or Other Parent's First Name

Middle Initial:

Last Name:

Social Security #:

Birthdate:

Relationship to Patient:

Employer:

Occupation:

Length of Employment:

Work Phone #:

Dental Insurance Information

Policy Holder's Name

Relationship to Patient

Policy Holder's Employer:

Insurance Company

Subscriber ID #

Group No.

Insurance Co. Address

City

State

Zip

Insurance Co. Phone No.

Do you have dual dental coverage?

NoYesIf so, please name the Insurance Company below:

Policy Holder's Name

Relationship to Patient

Policy Holder's Employer:

Insurance Company

Subscriber ID #

Group No.

Insurance Co. Address

City

State

Zip

Insurance Co. Phone No.

Emergency Information

Name of nearest relative not living with you

Complete Address

Phone

Relationship to Patient

Dental History

Dentist Name

Check-up Frequency

Last Dental Visit

Has the patient had an orthodontic consult or treatment?

NoYes

If so, when?

Does the patient need to premedicate prior to dental visit?

NoYes

What is the patient's main orthodontic concern?

Please select YES if the patient has had any of the conditions listed below either now or in the past.

Speech problems/therapy?

NoYes

Clench or Grind Teeth?

NoYes

Oral habits (thumb/finger sucking, lip/nail biting)?

NoYes

Injury to face, jaw, teeth or mouth?

NoYes

Discomfort from teeth or gums?

NoYes

Pain, tenderness or noise in either jaw?

NoYes

Frequent headaches?

NoYes

Neck / Shoulder Pain?

NoYes

Frequent sore throats?

NoYes

Chipped or injured permanent teeth?

NoYes

Teeth sensitive to hot or cold?

NoYes

Previous root canal therapy?

NoYes

Bad taste/mouth odor?

NoYes

Previous periodontal (gum) treatment?

NoYes

Abnormal swallowing (tongue thrust)?

NoYes

Teeth that irritate tongue, cheek, lip, etc?

NoYes

Numerous fillings?

NoYes

Brush teeth daily?

NoYes

Floss teeth daily?

NoYes

Fluoride treatments?

NoYes

Mouth breathing?

NoYes

Snores during sleep?

NoYes

Any missing or extra permanent teeth?

NoYes

Apprehensive about dental care?

NoYes

Frequently Chew Gum?

NoYes

Thumb or finger habit as a child?

NoYes

Jaw fractures, cysts, mouth infections?

NoYes

Bleeding gums?

NoYes

Other periodontal (gum) problems?

NoYes

Frequent canker sores or cold sores?

NoYes

Have wisdom teeth been removed?

NoYes

Problems with food trapped between teeth?

NoYes

Is all dental work completed?

NoYes

If any of the above dental questions were answered 'Yes', please explain:

Have you had a TMJ screening?

NoYes

Do you experience soreness in the muscles of your face or around your ears?

No Yes

Do you have a history of jaw joint problems?

NoYes

Have you been treated for TMJ?

NoYes

Do you notice clicking or popping in your jaw joint?

NoYes

Do you clench your teeth?

NoYes

Has your jaw ever locked?

NoYes

Do you have difficulty chewing or opening your mouth?

NoYes

Does your bite feel uncomfortable or unusual?

NoYes

If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name

Date of Last Physical

Patient Health

Address

City

State

Zip

Has there been any change in the patient's general health within the last year?

NoYes

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?

NoYes

Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?

NoYes

List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:

Latex

NoYes

Penicillin or other antibiotics

NoYes

Sulfa drugs

NoYes

Aspirin, Ibuprofen, Tylenol

NoYes

Local anesthetics

NoYes

Codeine or other narcotics

NoYes

Other

NoYes

List any drug allergies or sensitivities (not listed above) that the patient may have:

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Heart Murmur

NoYes

Damaged or artificial heart valves

NoYes

Congenital Heart Defect

NoYes

Heart Disease

NoYes

Rheumatic Fever

NoYes

Angina

NoYes

Liver Disease / Jaundice / Hepatitis

NoYes

Kidney Disease

NoYes

Heart Attack / Stroke

NoYes

Hemophilia

NoYes

Hypertension / High Blood Pressure

NoYes

Prolonged Bleeding / Transfusion

NoYes

Anemia / Blood Disorder

NoYes

HIV / AIDS

NoYes

Tonsils / Adenoids Removed

NoYes

Handicaps / Disabilities

NoYes

Arthritis / Joint problems

NoYes

Large Tonsils

NoYes

Sinus Trouble

NoYes

Bed Wetting

NoYes

Substance abuse problems (past or present)

NoYes

Bone fractures / Trauma to face / Jaw

NoYes

Prosthetic Joints

NoYes

Chronic Fatigue

NoYes

Diabetes

NoYes

Growth Problems

NoYes

Tuberculosis or Lung Disease

NoYes

Pneumonia

NoYes

Cancer

NoYes

Family History of Cancer

NoYes

Received Radiation Treatment

NoYes

Arterioscloerosis

NoYes

Thyroid / Endocrine Problems

NoYes

Stomach Ulcer or Hyperacidity

NoYes

Hormone Therapy

NoYes

Latex / Metal Allergy

NoYes

Nervous Disorders

NoYes

Bone Disorders/Bone Loss

NoYes

Seizures / Epilepsy / Neurological Disease

NoYes

Treated for Emotional Problems

NoYes

Asthma

NoYes

Respiratory Problems / Emphysema

NoYes

Persistent swollen neck glands

NoYes

Sexually Transmitted Disease

NoYes

Low Blood Pressure

NoYes

Persistent Cough

NoYes

FEMALES: Are you pregnant?

NoYes

Take Bisphosphonates (Fosamax, Boniva)

NoYes

If any of the above medical questions were answered 'Yes' , please explain:

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth - If your teeth could be changed, how would you like them to change?

Straighten Front Teeth

UpperLowerBoth

Straighten Back Teeth

UpperLowerBoth

Move Upper Teeth

ForwardBackward

Move Lower Teeth

ForwardBackward

Eliminate Spaces Between Teeth

UpperLowerBoth

Eliminate Crowding of Teeth

UpperLowerBoth

Make Line of Upper Teeth More Level

Other

Face - If your facial appearance could be changed, what would you change?

Move Upper Lip

ForwardBackward

Move Lower Lip

ForwardBackward

Show my teeth when I smile

MoreLess

Show my gums when I smile

MoreLess

Make my nose:

LongerShorter

Get rid of sag under lower jaw

Move chin:

ForwardBackward

Move chin:

LeftRight

Reduce the strain when I close my lips in my:

ChinLipsBoth

When my teeth touch make my lips:

Closer TogetherFarther Apart

Symptoms - If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.

In front of ears

LeftRightBoth

Below ears

LeftRightBoth

Above ears

LeftRightBoth

In my ears

LeftRightBoth

My temples

LeftRightBoth

My eyes

LeftRightBoth

My neck

LeftRightBoth

My shoulders

LeftRightBoth

My jaw joints

LeftRightBoth

My teeth

My sinuses

Other

Patients Under 18

If patient is under the age of 18, please answer the following questions:

Height

Weight

School

Grade

Has patient begun puberty:

NoYes

If patient is a girl, has menstruation begun:

NoYes

If patient is a boy, has their voice changed or have facial hair:

NoYes

Has the patient grown in the past year or has their shoe size changed recently:

NoYes

Has either biological parent ever had orthodontic treatment:

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.

I understand that where appropriate, credit bureau reports may be obtained.